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1 Image: Blend Images/Punchstock Image: Blend Images/Punchstock Image: Ablestock/Punchstock Copyright STFM Third Edition June Last Modified: April, 2014

2 2 Course Steering Committee Editors Wanda Gonsalves, M.D. A. Stevens Wrightson, M.D. Dental Consultant Joanna M. Douglass, B.D.S., D.D.S. Smiles for Life Editor Melinda Clark, M.D. Funded By The images in this presentation are not to be reproduced/downloaded for purposes other than personal use. Republication, retransmission, reproduction, or other use of the Licensed Material is prohibited.

3 3 Educational Objectives Recognize adult caries and periodontal disease. Understand the oral effects of common medications, alcohol, and tobacco. Identify factors including chronic medical conditions that influence oral health. Identify tooth changes with aging.

4 4 Educational Objectives Discuss oral health promotion. List indications for antibiotic prophylaxis for dental procedures. Understand management of dental procedures in anticoagulated patients. Identify common oral lesions. Describe management and appropriate referral.

5 Adult Oral Health and Disease Chapter Objectives Recognize adult caries and periodontal disease and refer patients for appropriate treatment. Learn how aging and chronic medical conditions affect oral health. Understand oral effects of common medications, alcohol, tobacco, and methamphetamines. Learn how to discuss oral health promotion with patients.

6 Prevention of Oral Disease 6 Preventive Steps Brush and floss regularly Avoid frequent snacking on sugary foods Use fluoride toothpaste Avoid alcohol and tobacco Minimize medications with oral effects Visit dentist regularly Diagram: POHEK

7 Brushing and Flossing 7 Techniques Brush at least twice a day Use a soft toothbrush Focus on the area where the tooth meets the gingiva Use a high quality electric toothbrush for best results Floss regularly to help disrupt the formation of plaque below the gum line and between the teeth Diagram: POHEK

8 Adult Caries 8 Risk Factors Shared by Adults and Children High bacterial counts Family history of caries Frequent eating of sugarcontaining foods Inadequate fluoride Low socioeconomic status Photo: Joanna Douglass, BDS, DDS Photo: John McDowell, DDS

9 Adult Caries 9 Additional Risk Factors Physical disabilities Make brushing and other oral hygiene activities more difficult Existing restoration or appliances Can trap food Most likely site of caries in an adult Photo: Steven Lepowsky, DDS Decreased salivary flow Caused by disease or medication places a patient at a much higher caries risk Medication Increase caries risk by decreasing salivary flow and high levels of sucrose

10 Root Caries 10 Causes In patients with gingival recession tooth roots become progressively more exposed Roots are more susceptible to caries than crowns of teeth With bacteria and a diet high in sugars, caries can develop easily and progress rapidly Treatment Lesions can be prevented or arrested using fluoride containing toothpaste, gels, or varnish Advanced lesions require restoration or extraction Photo: John McDowell, DDS Photo: Robert Henry, DMD, MPH

11 Gingivitis 11 Symptoms Tenderness Erythema Bleeding gums Mild gum swelling Bad breath Causes Plaque buildup Changes in hormone levels Oral foreign bodies Gum inflammation but no destruction of periodontal ligament or bone Treatment Good home hygiene Regular dental visits Photo: John McDowell, DDS Photo: Joanna Douglass, BDS, DDS

12 Periodontitis 12 Causes Chronic plaque exposure causes inflammation which leads to Destruction of periodontal ligament Loss of supporting bone Tooth loosening and loss 16 Treatment Good oral hygiene and regular dental visits Tobacco and other irritants, such as cannabis should be avoided Dental referral for deep root scaling Oral antibiotics and solutions such as chlorhexadine Photo: Efthimia Ioannidou DDS, MDS Photo: John McDowell, DDS

13 Tooth Changes with Aging 13 Normal Teeth and Gingiva (age 53) Worn, Yellowing Teeth (age 83) Yellow, Worn Teeth (age 90) Tobacco Staining (age 76) Photos: Robert Henry, DMD, MPH

14 Tooth Loss 14 Prevalence Over age 65 average 18 remaining teeth 25% of population lack teeth Negative Impacts Difficulty eating Inadequate nutritional intake Dissatisfaction with facial appearance Dentures Improve Quality of Life Provide support Improve appearance Make eating easier Without Dentures Photos: Robert Henry, DMD, MPH With Dentures

15 Oral Effects of Medication 15 Some medications may have oral side effects such as: Gum overgrowth (gingival hyperplasia) Dental erosion Dryness in the mouth (Xerostomia) Dental caries Break down of the jaw bone (osteonecrosis) Read side effects of medications and consult a physician

16 Gingival Hyperplasia 16 Symptoms Unsightly gingival enlargement Teeth become hard to clean Increased risk for Periodontitis Causes Poor hygiene Drug induced Underlying systemic disease Treatment Meticulous hygiene Regular cleanings May require gum resection surgery Consider alternative medications Photo: ICOHP Photo: John McDowell, DDS

17 Dental Erosions 17 Symptoms Teeth become smooth and glassy Pulp exposure causes hot and cold sensitivity Causes Bulimia GERD (Gastroesophageal Refulx Disease), or acid reflux Methamphetamine use Acidic drinks Treatment Rinse with water after reflux or vomiting Photo: POHEK Photo: John McDowell, DDS

18 Dryness in the Mouth (Xerostomia) 18 Symptoms Dry mouth Burning sensation Changes in taste Difficulty swallowing and speaking Increased caries experience Etiology Medications Systemic disease (e.g. Sjogrens) and treatment consequences (e.g. Radiation therapy) Treatment Eliminate medications that decrease salivary flow Encourage patients to drink water Advise patients to avoid caffeinated or sugary drinks Recommend use of high concentration topical fluoride Ensure regular dental care and good oral hygiene Recommend over-the-counter salivary substitutes

19 Alcohol and Tobacco 19 Effects of Tobacco Use Tooth stains Altered taste and smell Periodontitis Xerostomia Caries Oral, head, and neck cancers Congenital anomalies in offspring, such as cleft lip and palate Effects of Alcohol Use Periodontitis Xerostomia Caries Oral and throat cancers Fetal alcohol syndrome Congenital anomalies in offspring, such as cleft lip and palate

20 Meth Mouth 20 Symptoms Typical users:18- to 40-year old white males in rural, western regions Rampant caries, gingival recession, and dental erosion in young patients How the disease develops Drug-induced xerostomia Increased carbohydrate and sugary beverage consumption Poor hygiene and teeth grinding Direct acid effect of the drug Treatment Dental/oral surgery, referral, and behavior health intervention Photos: James Cecil, DMD, MPH

21 21 Chapter Objectives Common Oral Lesions Identify common oral lesions Describe management and appropriate referral Image: Comstock/Punchstock

22 Herpes Labialis 22 Symptoms Burning, itching, or pain hours before eruption Vesicles rupture, ulcerate, and crust within 48 hours. Etiology Reactivation of latent viral infection Treatment Administer topical or systemic antiviral agents. Photo: Brad Neville, DDS Photo: Ellen Eisenberg, DMD

23 Pyogenic Granuloma (skin growth) Symptoms Red, nonpainful, smooth, or lobulated mass Often bleeds when touched Usually develops on gingiva May be a few millimeters to several centimeters in diameter Causes Photo: Brad Neville, DDS Rapidly growing mass in response to local irritation Treatment Conservative surgical excision is an option. Recurrence uncommon unless incompletely removed, patient is pregnant or source of irritation remains. 23

24 Oral Ulcerations 24 Types of Oral Ulcerations Aphthous Traumatic Viral Herpes Coxsackie Other Bacterial Drug reaction Photo: Ellen Eisenberg, DMD Photo: Joanna Douglass, BDS, DDS

25 Geographic Tongue 25 Symptoms May produce pain or burning, especially with spicy foods Most often asymptomatic Increases & decreases in size, migrates Causes Exact causes uncertain Treatment Typically no treatment is required Topical steroids gels and antihistamine mouth rinses can reduce tongue sensitivity Photos: Brad Neville, DDS

26 Hairy Tongue 26 Symptoms Most patients are asymptomatic Some patients may experience halitosis (bad breath) or abnormal taste Causes Associated with tobacco use, poor oral hygiene, and antibiotic use. Preventive Measures Improves with avoidance of tobacco, mouthwashes, and antibiotics Regular tongue brushing with soft toothbrush or tongue scraper may help. Photo: Brad Neville, DDS

27 Fissured Tongue 27 Symptoms Usually asymptomatic Number, depth, and direction of fissures varies considerably Food debris may lodge between the fissures leading to bad breath and rarely irritation 10-20% also have geographic tongue Causes Exact cause uncertain Associated with increasing age and dry mouth Preventive Measures Tongue brushing important to remove food trapped in fissures Photo: Brad Neville, DDS

28 Bony Tori 28 Symptoms Non-cancerous bony bulge in mouth Develop in adulthood Present in 20-35% of population Treatment Surgical removal is required only if torus: Affects oral function Interferes with denture fabrication Is subject to recurrent trauma or surface ulceration Palatal Tori Photo: Brad Neville, DDS Mandibular Tori Photo: John McDowell, DDS

29 Candidiasis 29 Causes Overgrowth of yeast in the mouth Immunosupressed states Poorly fitting and infrequently removed dentures and oral appliances Pseudomembranous Candidiasis Often referred to as thrush Most common form May present with burning sensation Treatment Administer topical or antifungal agents Remove, clean and adjust fit of dentures and appliances Photo: Brad Neville, DDS Photo: Joanna Douglass, BDS, DDS

30 Oral Cancer 30 Prevalence 90% of oral cancers are squamous cell carcinomas 60% of oral cancers are advanced at time of detection Alcohol and tobacco are principal risk factors Strong etiologic association between HPV and oropharyngeal cancers HPV positive cancers are more frequent in white men and people who do not use tobacco or alcohol. 50% 5 year survival rate Photo: Ellen Eisenberg, DMD Photo: Robert Henry, DMD, MPH

31 Oral Cancer 31 Seek Medical help when Red or white lesions persist more than two weeks Mouth sores won t heal or bleed easily Cancers most commonly develop on the tongue, floor of mouth, and between the lower lip and gums Cancer-prone areas are indicated by yellow dots. Diagram: AAFP Home Study Program with permission

32 Denture Problems 32 Denture Care Remove dentures at night Brush with denture brush or soft toothbrush Place in denture cleanser soaking solution or in water overnight Some patients may need a caregiver to manage this aspect of oral hygiene Photos: Robert Henry, DMD, MPH

33 33 Take Home Messages Don t assume patients are seeing a dentist on a regular basis CHWs should provide patient education and appropriate referral Counsel appropriate oral preventive practices

34 34 Questions? Image: Jupiterimages/Photos.com